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Surgical Management of Symptomatic
Olecranon Traction Spurs
Hasham M. Alvi,* MD, David M. Kalainov,*
†
MD, Debdut Biswas,
‡
MD,
Alexander P. Soneru,* MD, and Mark S. Cohen,
‡
MD
Investigation performed at Northwestern Center for Surgery of the Hand, Chicago, Illinois, USA
Background: There is a paucity of information pertaining to the pathoanatomy and treatment of symptomatic olecranon traction
spurs.
Purpose: To describe the pathoanatomy of olecranon traction spur formation, a technique for spur resection, and a series of
patients who failed conservative care and underwent operative treatment.
Study Design: Case series; Level of evidence, 4.
Methods: Eleven patients (12 elbows) with a mean age of 42 years (range, 27-62 years) underwent excision of a painful olecranon
traction spur after failing conservative care. Charts and imaging studies were reviewed. All patients returned for evaluation and new
elbow radiographs at an average of 34 months (range, 10-78 months). Outcome measures included the Quick-Disabilities of the
Arm, Shoulder, and Hand (QuickDASH) questionnaire; the Mayo Elbow Performance Score (MEPS); visual analog scales (VAS) for
pain and patient satisfaction; elbow motion; elbow strength; and elbow stability.
Results: The traction spur was found in the superficial fibers of the distal triceps tendon in all cases. The mean QuickDASH score was
3 (range, 0-23), the mean MEPS score was 96 (range, 80-100), the mean VAS pain score was 0.8 (range, 0-3), and the mean VAS
satisfaction score was 9.6 (range, 7-10). Average elbow motion measured 3
to 138
(preoperative average, 5
-139
). All patients
exhibited normal elbow flexion and extension strength, and all elbows were deemed stable. Early postoperative complications involved
a wound seroma in 1 case and olecranon bursitis in 1 case: both problems resolved without additional surgery. Two patients eventually
developed a recurrent traction spur, 1 of whom underwent successful repeat spur excision 48 months after the index operation.
Conclusion: Short- to mid-term patient and examiner-determined outcomes after olecranon traction spur resection were accep-
table in our experience. Early postoperative complications and recurrent enthesophyte formation were uncommon.
Clinical Relevance: This study provides the treating physician with an improved understanding of the pathoanatomy of olecranon
traction spur formation, a technique for spur resection, and information to review with patients regarding the outcome of surgical
management.
Keywords: olecranon traction spurs; enthesophytes; triceps tendinosis; olecranon bursitis; weight lifting
Olecranon traction spurs are enthesophytes found in the
distal triceps tendon at the point of insertion into the
olecranon process. They are thought to arise as a result of
mechanical loading (ie, repetitive traction stress) and have
been found to grow by a unique combination of endochon-
dral, intramembranous, and chondroidal ossification.
2,6
An olecranon traction spur may be a source of substantial
elbow pain, alone or in combination with triceps tendinopa-
thy and olecranon bursitis.
3,4,10,12
There are few reports of
surgical treatment to address a painful enthesophyte at this
site, and sparse outcome data.
4,12
The purposes of this study
were to report the pathoanatomy of olecranon traction spur
formation, a technique of spur resection, and the clinical and
radiographic results at short- to mid-term follow-up.
MATERIALS AND METHODS
Study Population
The records of 12 patients who were treated surgically for a
painful olecranon traction spur by 4 attending orthopaedic
†
Address correspondence to David M. Kalainov, MD, Northwestern
Center for Surgery of the Hand, 737 North Michigan Avenue, Suite 700,
Chicago, IL 60611, USA (e-mail: dkalainov@comcast.net).
*Department of Orthopaedic Surgery, Northwestern University
Feinberg School of Medicine, Chicago, Illinois, USA.
‡
Midwest Orthopaedics, Rush University Medical Center, Chicago,
Illinois, USA.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The Orthopaedic Journal of Sports Medicine, 2(7), 2325967114542775
DOI: 10.1177/2325967114542775
ª The Author(s) 2014
1
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surgeons between March 2004 and March 2012 were
reviewed. Eleven patients (12 elbows) were contacted and
agreed to participate in this study, whereas 1 patient could
not be located and was excluded from analysis. The 11
patients who constituted this study were male, with an
average age of 42 years (range, 27-62 years). The dominant
extremity was involved in 7 cases, the nondominant extre-
mity in 3 cases, and both elbows were affected in 1 patient.
Institutional review board approvals were obtained from
our separate academic centers.
Posterior elbow pain developed in relationship to weight
lifting exercises in 4 cases and elbow trauma in 8 cases (new
pain or exacerbation of preexisting pain). At initial presen-
tation, there was point tenderness over the tip of the olecra-
non process and distal triceps tendon and/or posterior
elbow pain with resisted elbow extension in all cases. Five
patients had concomitant olecranon bursitis (1 with gouty
tophi), and 1 patient had lateral elbow pain compatible with
lateral epicondylitis. An elbow flexion contracture of 10
to
20
was measured in 4 cases. There were no motor or sen-
sory deficits in the involved extremities.
Preoperative radiographs of the affected elbows were
retrieved in 9 cases, and a preoperative ultrasound study
was retrieved in 1 case for assessment of triceps entheso-
phytes. The preoperative radiology and surgical reports
were used to confirm olecranon traction spur existence in the
remaining 2 cases. The available images showed bone spurs
projecting posteriorly or posterocephalad from the dorsal
extra-articular margin of the olecranon process. A fracture
through the spur was noted in 8 cases: 6 cases through the
base of the spur and 2 cases through the mid to distal portion
of the bony excrescence. Seven elbows had a small exostosis
and/or calcifications in the common extensor tendon origin
at the lateral epicondyle (all asymptomatic), and 4 elbows
had osteophytes around the perimeter of the posterior ulno-
humeral joint. Additional preoperative elbow imaging
included magnetic resonance imaging (MRI) in 5 cases and
a computed tomography (CT) scan in 1 case. The MR images
and the aforementioned ultrasound study revealed concomi-
tant distal triceps tendinosis.
All patients were managed conservatively for a mini-
mum of 3 months with various measures, including elbow
immobilization, elbow padding, anti-inflammatory medica-
tion, rest, activity modifications, and supervised therapy
modalities. Surgery was undertaken when these measures
failed to provide acceptable pain relief.
Surgical Technique and Postoperative Care
The procedures were performed under regional or general
anesthesia. A longitudinal incision was made over the ole-
cranon process and extended through the subcutaneous fat
and bursa. The incision was positioned lateral to the tip of
the olecranon process or curved gently around the process
to avoid scar sensitivity. Full-thickness skin flaps were
raised to expose the distal triceps tendon and bone attach-
ment. A limited bursectomy was completed in 3 cases, and a
complete bursectomy was completed in 4 cases (including
all 5 elbows with olecranon bursitis). Two patients under-
went concurrent resection of a symptomatic osteophyte
from the tip of the olecranon process, and 1 patient under-
went combined debridement of the common extensor ten-
don origin for treatment of lateral epicondylitis and elbow
arthroscopy for removal of a loose body.
A thin layer of triceps tendon tissue was found to overlie
the traction spur in each case and was incised longitudinally.
There were no patients with a gross tear of the triceps ten-
don by operative report, including the 1 patient who was
excluded from the study. The tendon tissue was elevated
from the dorsal, radial, and ulnar margins of the spur
(Figure 1A). The intact or fractured bony excrescence was
then excised using an osteotome and/or rongeur to the level
of the dorsal cortex, taking care to preserve deep triceps ten-
don attachments to bone (Figure 1B). Sharp bone edges were
smoothened with a rasp, and the adequacy of resection was
assessed with intraoperative fluoroscopy. The thin layer of
reflected triceps tendon was either resected (7 cases) (Figure
1C) or repaired with absorbable sutures (5 cases).
The elbow was temporarily immobilized with a splint in
flexion in all but 1 case. Elbow motion was permitted within
the first week after surgery, and a self-directed program of
elbow motion and strengthening was encouraged. Unrest-
ricted activities were permitted between 3 and 6 weeks
postoperatively.
Outcome
All patients agreed to return specifically for the purposes of
this study at an average of 34 months (range, 10-78 months)
after primary (11 cases) or recurrent (1 case) spur excision. A
physician or a physician assistant evaluated each patient
with help from an occupational therapist in most cases.
Outcome assessments included the Quick-Disabilities of the
Arm, Shoulder, and Hand (QuickDASH) questionnaire; the
Mayo Elbow Performance Score (MEPS); visual analog
scales (VAS) of patient pain and satisfaction; measurements
of elbow motion and strength; and an assessment of elbow
stability.
The QuickDash questionnaire includes 11 items that
gauge function applicable to upper extremity musculoske-
letal disorders. The score is based on a scale of 0 to 100
points, with a lower score reflective of a better outcome. The
MEPS includes 5 patient and examiner-determined cate-
gories and is also based on a scale of 0 to 100 points, but
with a higher score reflective of a better outcome. The VASs
include numeric responses on a scale from 0 to 10, with 0
representing no pain and poor satisfaction and 10 repre-
senting severe pain and high satisfaction.
Active elbow joint motion measurements were obtained
with a handheld goniometer. Elbow strength was assessed
with manual muscle testing and categorized using the Medi-
cal Research Council of Great Britain grading system. Elbow
stability was gauged by applying varus and valgus stresses
and by comparing with laxity in the contralateral elbow.
Early postoperative radiographs of the elbow were
retrieved in 9 cases, and new follow-up radiographs of the
elbow were completed in all 12 cases. Adequate spur resec-
tion was confirmed by reviewing the early postoperative
radiographs and radiograph reports. Spur dimensions in the
sagittal plane were measured on the available preoperative
2 Alvi et al The Orthopaedic Journal of Sports Medicine
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digitized radiographs (9 cases) and the new follow-up digi-
tized radiographs (12 cases). The preoperative spur dimen-
sions in 1 additional case were obtained from digitized
ultrasound images of the elbow. Spur length was measured
from the base to the tip of the intact or fractured excrescence,
and spur width was measured across the base of the excres-
cence, as depicted in Figure 2.
RESULTS
One patient developed a wound seroma 4 days after entheso-
phyte resection and concomitant bursectomy. The fluid was
aspirated twice, and swelling resolved after 3 weeks. One
patient developed olecranon bursitis 7 weeks postoperatively
that resolved with a compressive sleeve, and 1 other patient
returned to surgery after 6 months for removal of prominent
suture material from the distal triceps tendon.
At the latest follow-up assessment, all patients stated that
pain in the operative elbow(s) had improved. The mean Quick-
DASHwas3(range,0-23),themean MEPS was 96 (range, 80-
100), the mean VAS pain score was 0.8 (range, 0-3), and the
mean VAS satisfaction score was 9.6 (range, 7-10). The patient
with the lowest VAS satisfaction score attributed the initial
onset of elbow pain to an injury that occurred at work.
Elbow motion was nearly equivalent before and after
treatment in each patient. Mean active elbow motion mea-
sured 5
(range, 5
to 20
) to 139
(range, 125
-145
)of
flexion preoperatively and 3
(range, 0
-10
) to 138
(range,
125
-149
) of flexion at final evaluation. Normal elbow flex-
ion and extension power were demonstrated, and all elbows
were deemed stable by stress examination.
Mean spur length before the index operation was 14 mm
(range, 7-23 mm), and mean spur width was 6 mm (range,
3-9 mm). At the latest follow-up assessment, radiographs
Figure 2. Lateral radiographic image of an elbow depicting the
technique for measuring spur dimensions. A straight line is
drawn along the posterior margin of the olecranon process and
through the base of the spur. Spur length is measured from
points A to B, and spur width is measured from points A to C.
Figure 1. Spur resection technique. (A) A longitudinal incision is made over the olecranon process, and full-thickness skin flaps are
raised to expose the distal triceps tendon attachment. A thin layer of triceps tendon tissue overlying the spur is incised longitudin-
ally, and the tissue is reflected from the dorsal, radial, and ulnar margins of the spur. (B) The spur is elevated and excised, exposing
the deeper triceps tendon attachment to bone. (C) The reflected layer of tendon tissue is debrided to healthy-appearing tissue.
The Orthopaedic Journal of Sports Medicine Olecranon Traction Spurs 3
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showed well-circumscribed calcifications corresponding to
the distal triceps tendon in 4 cases (Figure 3).
Two patients developed a recurrent olecranon traction
spur. The bony excrescence in 1 case was detected in radio-
graphs that were completed specifically for this study
78 months postoperatively. The spur was not tender and
measured 10 mm in length and 8 mm in width. In the other
case, posterior elbow pain recurred, and a spur was
detected by radiographs 38 months after the index proce-
dure (these images were not available for review). This
patient elected to undergo additional surgery 10 months
later, and his pain resolved. Final radiographs 53 months
later showed no new spur formation.
DISCUSSION
Pain attributable to an olecranon traction spur may develop
spontaneously, after a traumatic event, or in association
with sport activities.
1,3,8,15
In agreement with other authors,
distal triceps tendinosis as discerned by ancillary imaging
and/or clinical examination and a fracture through the
spur were common findings in our series.
3,4,10,12
In con-
trast, olecranon bursitis was detect ed in less than half of
our patients.
1,3,9,12-14
An asymptomatic exostosis and/or asymptomatic calcifica-
tions were seen at the lateral epicondyle in slightly more than
50% of cases, but of uncertain relationship to the distal triceps
tendon enthesophytes. Posterior compartment degenerative
arthritis was seen in only 4 elbows, suggestive of disparate
pathophysiologic processes.
5
The olecranon traction spur was located in the superfi-
cial portion of the distal triceps tendon in each case,
consistent with growth of traction spurs at other tendon
insertion sites.
2
Debridement of the thin covering of tri-
ceps t endon tis sue and spur resection did not adversely
affect elbow motion or extension power, presumably due
to preservation of deep tendon attachments to bone.
7
A
recent cadaveric study revealed a fairly large triceps ten-
don footprint on the olecranon process that averaged 466
mm
2
.
16
Mair et al
8
found that nonoperative treatment was
possible with a traumatic triceps tend on tear involving
75% ofthetendonbyMRI,andVidaletal
15
proposed that
a triceps tendon tear of less than 50% could be treated non-
surgically with satisfactory results.
Patient and examiner-determined outcomes were favor-
able at the latest evaluation in nearly all of our cases. Early
postoperative complications were limited to a transient
wound seroma in 1 elbow and temporary olecranon bursitis
in 1 elbow. One patient underwent removal of a prominent
suture in the triceps tendon 6 months after surgery, and 2
patients developed a recurrent distal triceps tendon enthe-
sophyte, 1 of whom was symptomatic and underwent addi-
tional surgery 4 years later. There was no recurrence of a
spur in this case at final evaluation approximately 4.5 years
after the second operation.
Limitations of this study include the retrospective
design and the small number of patients. There were
insufficient case numbers to compare potential differences
in outcomes between triceps tendon debridement and
repair, or between patients with and without a fracture
of the enthesophyte. Preind ex surgery radiographs were
missing in 3 c ases, recurrent spur formation radiographs
were missing in 1 case, subjective scores of elbow pain
and function before surgery were not obtained, and post-
operative rehabilitation measures were not standardized.
Figure 3. Lateral radiographic images of the same elbow in Figure 2. (A) Three weeks after spur excision and (B) 17 months after
spur excision showing spotty calcifications corresponding to the distal triceps tendon.
4 Alvi et al The Orthopaedic Journal of Sports Medicine
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Furthermore, clinical evaluations were completed by the
treating surgeon in several cases with th e potential f or
introducing bias.
11
Excision of painful olecranon traction spurs was found to
provide improvement in pain and a generally high patient
satisfaction at short- to mid-term follow-up. Although
long-term outcome data are necessary, our experience sup-
ports excision of persistently symptomatic olecranon trac-
tion spurs to be a reasonably safe and effective treatment.
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